Systematic Reviews
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. Jan 21, 2022; 10(3): 939-953
Published online Jan 21, 2022. doi: 10.12998/wjcc.v10.i3.939
Atrial fibrillation burden and the risk of stroke: A systematic review and dose-response meta-analysis
Sheng-Yi Yang, Min Huang, Ai-Lian Wang, Ge Ge, Mi Ma, Hong Zhi, Li-Na Wang
Sheng-Yi Yang, Min Huang, Ge Ge, Mi Ma, Department of Epidemiology and Biostatistics, Southeast University, Nanjing 210009, Jiangsu Province, China
Ai-Lian Wang, Yaohua Community Healthcare Center, Nanjing 210046, Jiangsu Province, China
Hong Zhi, Department of Cardiology, Zhongda Hospital, Nanjing 210009, Jiangsu Province, China
Li-Na Wang, School of Public Health, Southeast University, Nanjing 210009, Jiangsu Province, China
Author contributions: Yang SY and Huang M designed the search strategy, performed the literature search and collected the data; Yang SY wrote the manuscript; Ma M checked the data; Ge G performed quality assessment and reviewed the level of evidence; Wang LN designed the project and edited the manuscript; Zhi H helped revised the manuscript for language; Wang AL checked the data; all authors read and approved the manuscript.
Supported by National Natural Science Foundation of China, No. 81673259; and Natural Science Foundation of Jiangsu Province, China, No. BK20161435.
Conflict-of-interest statement: There is no conflict of interest.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Li-Na Wang, Doctor, Associate Professor, School of Public Health, Southeast University, No. 87 Ding Jiaqiao Road, Nanjing 210009, Jiangsu Province, China. lnwang@seu.edu.cn
Received: September 2, 2021
Peer-review started: September 2, 2021
First decision: October 11, 2021
Revised: October 26, 2021
Accepted: December 23, 2021
Article in press: December 23, 2021
Published online: January 21, 2022
Abstract
BACKGROUND

The increased stroke risk associated with atrial fibrillation (AF) burden exceeding 5 min is a matter of debate. In addition, the potential linear or nonlinear relationship between AF burden and stroke risk has been largely unexplored.

AIM

To determine the association between AF burden > 5 min and the increased risk of stroke and explore the potential dose-response relationship between these two factors.

METHODS

Sixteen studies from six databases with 53141 subjects (mean age 65 years) were included. Fifteen studies were observational studies, and one was a randomized controlled trial study. The potential nonlinear dose-response association was characterized using a restricted cubic splines regression model. AF burden for each 1 h and 2 h was associated with an increased risk of stroke. Trial sequential analysis with a random-effect model was used to evaluate the robustness of the evidence from the included 16 studies.

RESULTS

AF burden > 5 min was associated with an increased risk of clinical AF [adjusted risk ratio (RR) = 4.18, 95% confidence interval (CI): 2.26-7.74]. However, no association was found with an increased risk of all-cause mortality (adjusted RR = 1.55, 95%CI: 0.87-2.75). Patients with AF burden > 5 min had an increased risk of stroke (adjusted RR = 2.49, 95%CI: 1.79-3.47). Moreover, a dose-response analysis showed that the increased stroke risk was paralleled by an increase in AF burden at a rate of 2.0% per hour (Pnonlinear = 0.656, RR = 1.02, 95%CI: 1.01-1.03). Trial sequential analysis provided robust evidence of the association between AF burden > 5 min and an increased risk of stroke.

CONCLUSION

AF burden was a significant risk factor for clinical AF and future stroke. A significant linear association was documented between increased AF burden and risk of future stroke.

Keywords: Atrial fibrillation, Stroke, Dose-response, Meta-analysis, Risk

Core Tip: We performed a systematic review and meta-analysis to determine whether atrial fibrillation (AF) burden > 5 min was associated with increased risk of stroke and to explore the dose response effect of AF burden on the future stroke. A significant linear association was documented between increased AF burden and risk of future stroke.